NHS 111

So wait, let me get this straight:

You decide that your existing nurse-led telephone advice service, NHS (re)Direct, isn't producing the appropriate yet safe clinical advice that you would like it to, and you'd like to replace it with a better and cheaper system. Mainly cheaper.

You decide that the best way to do this would be to replace the nursing staff whose job is to triage patients over the telephone with people who have no medical training, and you expect that this will make the clinical advice given to patients safer and more effective. You think that this will help take the pressure off the enormously overburdened emergency departments.

What? We pay you to run a national health system? WE pay YOU to run OUR national health system?

We must be out of our minds.

Value for money post: the vagus nerve, mathematics, systems theory and bowel movements

To quote Gray's, the anatomy bible:

the vagus nerve is composed of both motor and sensory fibers, and has a more extensive course and distribution than any of the other cranial nerves, since it passes through the neck and thorax to the abdomen.

The spelling of "fibers" and Oxford comma belong to the author, although I do love a good Oxford comma.

For the uninitiated, it carries parasympathetic fibres to the thoracic and abdominal organs. These provide the opposite of the sympathetic 'fight or flight' response; instead, they encourage the body to perform functions suitable for a nice relaxing afternoon. The heart slows down and its muscles contract less forcefully when vagal tone increases, whilst the gut blood flow increases and muscle activity increases to digest food, absorb nutrients from it and pass waste in the form of faeces.

Unfortunately, if you are a youngster in heart failure and you go to the bathroom and try very hard to open your bowels, your vagal tone can increase much more than is good for you, and can instantly put you into a state called cardiogenic shock; your heart is no longer pumping out enough blood to oxygenate you adequately, and you become shockingly unwell unbelievably quickly.

This, it goes without saying, can break up the gentle routine of an afternoon on the ward. Trying to engage your insulin-saddled post-lunch brain into quickly prescribing and preparing a 10 microgram/kg/minute infusion of dobutamine, a task which should be reasonably straightforward (although inevitably double or triple-checked) at the best of times, can suddenly become a feat of mathematical impossibility.

Obviously, as Murphy's law would have it, the protocol for prescribing a dobutamine infusion would disappear at the exact time it was most urgently required. Reason's 'Swiss Cheese Model' suggests defects in multiple layers of protective measures must all line up to lead to disrupt the system; meanwhile, a speaker at a study day I recently attended suggested that "the hallmark of an unsafe medical system is a person at the end of any process who has to perform flawlessly."

Luckily, we have people like that. We call them nurses. "Put x mg into 50ml of saline and infuse at 2ml/hr to run at 10," she told me. I double-checked the maths. It worked.

After all that, the PICU team decided they'd start dobutamine on the unit. Typical.

The GMC and social media

Thanks to the ever-wonderful xkcd for this

The General Medical Council claims its purpose is "to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine". There are more than 250,000 doctors on the list of registered medical practitioners, each paying a significant annual fee to the GMC. It would be nice if the results of this could be seen in published dramatic and substantial patient safety research, although sadly that's not the case.

The GMC this year published guidance for doctors on the use of social media. It helpfully explained what social media was, to aid the less technogically-savvy doctor (just in case a consultant thought the Twitter app on his new phone was a 'to-do' list to enter confidential patient information into and keep it safe, I assume), and also offered this spectacular piece of guidance:

17 If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

I suspect that it is purely coincidental that a lot of anonymously-written and excellent blogs within the blogosphere often criticised the healthcare establishment, whether that be short-term thinking feeding governmental interference in the system, or the GMC's laboured, prolonged and continued response to a rogue Hyde GP playing God for decades. I cannot for the life of me imagine any reason why an organisation would create guidance purely to silence its critics.

Whatever the reasoning behind this guidance, it has led to a dramatic decline in the number of anonymously-written medical blogs from the UK. Some have hung up their witty handles and publicly declared themselves, some have simply stopped writing, whilst some are retired, have little to fear from our erstwhile and conscientious regulators and therefore couldn't care less.

This blog has been neglected for some time now. Well, probably since conception. However, the correct way to counter oppression is to fight it directly, and I have been trained that blowing whistles is an honourable thing, but putting your name at the end of that whistle is a death knell for one's career. This means that I could continue to write as a junior doctor and remain anonymous, but this would mean breaching paragraph 17.

I'd therefore like to declare that I choose not to identify myself as a doctor. To be honest, this is the internet, and so even if I claimed to be a doctor, I probably wouldn't be, or I'd be one of those crazy people who thinks homeopathy is scientifically valid. I shall therefore leave my daytime (and often night-time) occupation to your imagination. Any connection between the views expressed on this blog and the views of the medical profession as a whole are purely coincidental.

I hope that clarifies things. In the meantime, I might as well start blogging again, given that no-one else seems to be.

Constipation

Quote of the night from yesterday, by a father whose daughter had presented with a 3 day history of 4-5 loose stools a day and lower abdominal pain, on a background of being completely well and having one soft, formed stool a day:

"It's not constipation is it?"

Help me.

Another hug

Thinking about the last hug made me think about a hug from long ago.

Some years ago, I was a surgical house officer working at a moderately-sized district general hospital. I was working the weekend. On Friday lunchtimes, the surgical teams all came together and had a big handover, where they'd discuss the patients they were concerned about and handover any weekend jobs. E, my colleague from another team, told me about Mrs V. Yep, I used to see adults as well. This one was quite small though, so I'm letting this post through on a technicality.

Mrs V had come in the prior weekend with large bowel obstruction. She had a distal stenosis in her colon, and the general opinion was that this was a cancer. She'd been for an endoscopy on the Monday and the consultant had managed to manoeuvre a stent past the blockage from underneath. This is a sprung tube, which can open up blocked passages. In surgical patients, these are a short-term measure; they release the pressure on the near side of the blockage temporarily, allowing the bowel to be more settled and thus easier to permanently repair.

However, the consultant was so delighted with this stent that he decided to sit on it all week, and ignore the warnings from the radiologists who kept doing follow-through tests to check its function that it was slipping and the opening was becoming narrower. E's handover wanted an early review for Mrs V, because if she was showing signs of re-obstructing, she would need to go to theatre sooner rather than later.

I saw her that night, and she was having diarrhoea - an early sign of obstruction (as the bowel is faced with a partial blockage, it works harder to push everything through it, meaning liquid stool moves through and reaches the outside faster - a concept known as overflow). I wrote quite clearly in the notes that this diarrhoea was not infective, and the patient should not be moved as they required an early review the next day.

I was called away from the ward round the next morning to attend an unwell patient elsewhere, and therefore did not realise the patient had not been seen, having been moved overnight to a side room elsewhere given the possibly infectious nature of her diarrhoea. The first I heard of this was at 12:30pm, when I strolled onto the orthopaedic ward to review a patient they were concerned about.

It was Mrs V. She looked dreadful. Tender abdomen, sweaty, pale. A quick blood gas revealed a lactate of 3.4 - not good. I thought she'd at least reobstructed, if not perforated. I order x-rays, bleeped my registrar and started some fluids.

The x-rays showed she had free air in her abdomen - she had perforated. The registrar wandered off to find a theatre. I repeated her blood gas - the lactate was now 6. Lactate, or lactic acid, is the stuff that builds up in your muscles and causes cramp when they're under anaerobic strain during exercise - it is a by-product of anaerobic respiration. Apart from a few rare metabolic disorders, a high lactate is usually a sign of poor perfusion; if insufficient oxygen is delivered to the tissues, more anaerobic respiration occurs, and the lactate rises. A rough rule of thumb; in severe sepsis, the lactate multiplied by 10 is your approximate mortality percentage. Not good.

I went back into the room, and Mrs V was weakly calling me over. She appeared to want to tell me something, so I moved closer, and she almost leapt off the bed and wrapped her arms around me, whispering in my ear, "thank you". She got progressively sicker whilst we waited for the orthopaedic team to finish - a 3 hour operation took them 5 hours 30 minutes, apparently for little other than the consultant's vanity - and by the time we got her into theatre, her entire gut was dead. She never woke from her anaesthetic.

When I'm dealing with very sick patients, I tend to make it fairly impersonal. It lets me think better and it stops me getting too attached. In this case, the hug ruined that for me. Mrs V stood out in my mind, because of that brief moment of human interaction. She still does.

Hug

Some people are unlucky enough to have to do the long day after the induction programme. Your first experience of a brand new way of working, and it's after hours. I had this experience recently. I had to get venous access and take pre-op bloods on an incredibly cute four year old who was having her tetralogy of Fallot repaired the next day. Cardiac kids have no veins. They're famous for it.

It doesn't stop you trying though. I aimed, I entered the skin with the needle, I probed, she cried, I hit something and got a little bit of flashback (blood brought into the end of the cannula through suction, to let you know you're in a vein), but couldn't advance it. She cried more. I took it out eventually, after she moaned and moaned and moaned that this was what she wanted, and held some gauze on her hand (which, of course, was now pouring with blood - they like to do that when you've been unable to get the cannula in).

I looked really sad at her. It wasn't a hard look to muster; I hate missing with cannulas, and I hate putting kids through unnecessary trauma. Evidently, this sad look was pretty convincing, as she looked at me, then launched herself forward off the bed and gave me this really big hug.

I'm lucky. I get to do some pretty amazing stuff at work. Sometimes, though, the thing that still makes you smile at the end of the day is the tiniest little thing like a spontaneous bit of comforting from somebody who has every right to be upset with you.

Guilt

It was my birthday yesterday, so I went out with a couple of friends and found myself in a slightly tipsy state, arriving home in the early hours. My rota has been a little busy of late - 17 shifts, seven of them 13 hours long, in 18 days - and with the weekend off, I fancied a nice lazy hungover Saturday, as advised by wise words from elsewhere.

Imagine my surprise when awoken at nine thirty by the sound of my telephone ringing. It was the consultant on call. The SHO for the weekend wasn't feeling well, and she asked me whether I could come in later on once I had sobered up and work a late shift.

I declined. I've been working hard, my sleep patterns aren't the healthiest at present for various reasons, and I've really been looking forward to this downtime. I think I need it. I told her that I was still drunk and I suspected I wouldn't be well enough to work later today.

It's now 4pm, and I feel a little fuzzy, but generally okay. I am following my original intention and having a lazy day. However, I can't fully enjoy the glory of doing nothing of note, because I'm feeling guilty. Work are short. They've asked me to come in. I've said no, and for good reason, but I can't help but feel like I'm letting them down.

Is this a situation unique to medicine? Do people with other jobs feel like this? Do I just need to get over the fact that I am not completely and uniquely essential to the running of the NHS?